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1. Reverse total shoulder replacement (RTSR) was examined as a potential treatment for end-stage shoulder arthritis.

2. After analysing the risk factors, RTSR was shown as a potential alternative treatment to total shoulder replacement for those with an intact rotator cuff.

Evidence Rating Level: 1 (Excellent)

One treatment for end-stage shoulder arthritis that is increasingly popular is shoulder replacement therapy. Reverse total shoulder replacement (RTSR) has previously been used for rotator cuff arthropathy but has expanded its use for other indications despite a lack of supporting evidence.

To better understand the effectiveness and economic implications of RSTR, a population-based prospective cohort study was conducted on shoulder replacement patients. Since the study focused on RTSR, patients aged 60 years or older who had an intact rotator cuff and a total shoulder replacement (TSR) or an RTSR were eligible to participate.

The study’s main outcome was revision surgery at any time as this represented survival of the implant. Serious adverse events within 3 months of surgery, lengthened stay in the hospital, reoperations within 1 year of surgery and a change in the Oxford shoulder score were examined as the secondary outcomes. Logistic regression was used to generate propensity scores representing the likelihood of a patient receiving an RSTR as opposed to a TSR and was based on several covariates such as age, previous shoulder surgery, and past medical history.

After excluding missing data for 175 procedures (1.3%) and for 7903 (61%) preoperative and 6448 (50%) postoperative Oxford Shoulder Scores, 11 961 patients were included with 12 986 elective shoulder replacement surgeries. The covariates were balanced after one-to-one propensity score matching (n=7124; TSR: 3562, RTSR: 3562) and adjustment of inverse probability (n=12 968; TSR: 9393, RTSR: 3575). Of the matched cohort, there were 126 revisions (1.8%; TSR: 85 RTSR: 41) that had a maximum follow-up time of 8.75 years with an observation period of 24 353 years (TSR: 14 332, RTSR: 10 021). Whereas in the weighted cohort, there were 294 revisions (2.3%; TSR: 253, RTSR: 41) that had 8.75 years of maximum follow-up, and 47 886 years of observation (TSR: 37 842, RTSR: 10 044). After three years, the observed risk for a TSR was shown to (hazard ratio local minimum 0.33, 95% confidence interval (CI) 0.18 to 0.59) compared to an RTSR revision which showed a non-significant postoperative hazard ratio (1.39 [95% CI 0.61 to 3.17]). The relative risk of reoperations decreased by half (odd ratio 0.45, 95% CI 0.25 to 0.83) within one year after RTSR. Further, there was an absolute risk difference of -0.51% (95% CI -0.89 to -0.13).

After comparing the benefits and risks, RTSR was an appropriate treatment for individuals aged 60 years or older with osteoarthritis.

Click to read the study in BMJ

Image: PD

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